The safety of residents and resident care are integral to the quality of care provided in nursing homes. Studies have shown that patient safety culture, defined as the outcome of a concerted organizational effort to move towards safety, is poorly developed in nursing homes and patient safety culture scores tend to be considerably lower than those of hospitals. Therefore, residents of nursing homes may be at risk of harm. Few studies have examined patient safety in nursing homes despite the growing recognition of the importance in understanding what predicts more favorable levels of patient safety. In particular, evidence is needed to ascertain the role nursing home patient safety culture plays in avoiding adverse resident outcomes. Using the revised version of Donabedian's Structure-Process-Outcome (SPO) Model, which also includes organizational attributes such as culture, this study examines the relationships between top management's ratings of nursing home patient safety culture (a structural attribute), and objective measures of safe processes of care and resident outcomes. To complete this secondary data analysis, this project will utilize three data sources: 1) the Agency for Healthcare Research and Quality Nursing Home Survey on Patient Safety Culture completed in 2008 by nursing home administrators and directors of nursing from a nationally representative sample of 4000 U.S. nursing homes, 2) data from the 2008 Online Survey Certification and Reporting Database, and 3) the 2008 Minimum Data Set. Restraint use and catheterization of residents will be used as measures of processes, and pressure sores, falls, and urinary tract infections will be used to measure patient safety outcomes. To examine if the patient safety culture of nursing homes is related to processes of care and patient safety outcomes, this study will utilize an advanced statistical approach to model multilevel data, namely two-level hierarchical generalized linear models. The ultimate goal is to find ways to improve the quality of health care through an understanding of the relationship between a culture focused on safety, care processes, and patient safety outcomes. These first research findings hopefully should contribute to the development of a patient safety culture in nursing homes and promote improvements in health care that can be measured by processes of care and resident outcomes. PUBLIC HEALTH RELEVANCE: Patient safety is a critical aspect of nursing home care and there is a growing recognition of the importance in understanding what predicts higher levels of patient safety. In particular, evidence is needed to ascertain the role nursing home patient safety culture plays in avoiding adverse resident outcomes. Therefore, it is important to understand the relationship of patient safety culture, processes of care, and patient safety outcomes.